HEALTH HISTORY (Check the Boxes of Your Past and Current Health Conditions)

MEDICAL FORM

(to be completed by applicant)

ABOUT THIS FORM: We inquire about certain health issues out of respect for the needs of each individual person and of the needs of the community. Past medical history with physical and/or mental health concerns does not remove you from consideration; however, your openness to discussing the issues helps MVC know how to best support you and your potential community during the upcoming year.

INSTRUCTIONS: Applicants for placement in Guyana should submit the forms WITH your application to Keri Young at . Applicants for placement in U.S. cities should submit FOLLOWING acceptance into MVC to Marie Schultz-Stebel at .

NAME: DATE:

HEALTH HISTORY (check the boxes of your past and current health conditions)

q  Allergies

q  Anemia

q  Arthritis

q  Asthma

q  Cancer

q  Chicken Pox

q  Colitis

q  Diabetes

q  Heart Disease

q  Hypertension

q  Kidney Disease

q  Measles

q  Menstrual Problems

q  Migraines

q  Mononucleosis

q  Mumps

q  Ovarian Cysts

q  Peptic Ulcer Disease

q  Seizures

q  Thyroid Disease

q  Tuberculosis

q  Urinary Tract Infection

q  Other:

Please explain the status of any conditions:

CURRENT HEALTH STATUS

A.) Briefly describe your general state of health:

B.) Are there any medical conditions which might affect your service assignment (detail physical challenges, chronic illnesses, restrictions, etc.)?

C.) Do you use a wheelchair, artificial limb, hearing aid, crutches or another sensory or mobility aid? Please explain.

D.) Have you ever had to modify your activities because of ill health or disability? Please explain.

E.) Have you had any operations/hospitalizations/significant injuries? Please explain.

F.) List any allergies, symptoms that you experience from exposure to allergens (rash, breathing problems, etc.), and any medication you use to treat these allergies.

PERSONAL HEALTH HABITS

A.) Do you smoke cigarettes? If yes, how many per day?

B.) Do you consume alcohol? If yes, how often?

C.) Recreational/street/prescription drug use – list history (or occasion) of drug use:

C.) Average number of sleeping hours per day?

Do you wake up tired? Do you have sleeping or early awakening problems?

E.) How many times per week do you exercise?

F.) Dietary restrictions:

MENTAL HEALTH

A.) Have you ever had counseling for personal growth or for emotional or psychological problems? Please comment on the reasons for counseling, the length of time, the benefit to you, and any medication prescribed. Do you anticipate needing to continue treatment over the course of the year?

B.) Do you have a history with eating disorders? Please explain.

C.) Have you ever been significantly under or overweight? Please explain.

D.) Have you ever felt suicidal or attempted suicide? Please explain.

E.) Have you ever experienced symptoms such as anxiety, depression, manic episodes, psychotic episodes, paranoia, etc? Have these symptoms been severe enough to require treatment? Please explain.

F.) Have you ever received a mental health diagnosis from a mental health professional (such as, but not limited to: depression, anxiety, bi-polar, borderline, schizophrenia)? Please explain.

G.) If you answered “yes” to any of the above questions, what plans do you have for self-care and treatment while a Mercy Volunteer?

H.) Sometimes our staff has asked volunteers to seek counseling if they display unhealthy behavior or if their behavior negatively affects work or community life. How would you respond if MVC staff recommended that you seek counseling?

PHYSICAL EXAMINATION FORM

(to be completed by medical professional, preferably one who has been involved with the applicant’s ongoing care)

TO THE MEDICAL PROFESSIONAL

Mercy Volunteers provide full-time service to sites which address the needs of the poor and marginalized. While living in an intentional community with other volunteers, Mercy Volunteers devote themselves to a simple lifestyle. This form will be used to assess that the applicant is fit for a full-time service placement of 40 hours per week, and to ensure s/he is placed where appropriate resources are available.

Information disclosed in this form will be kept confidential.

APPLICANT INFORMATION

Name: Date of Exam:

Length of time the applicant has been your patient:

GENERAL PHYSICAL INFORMATION

A.) Height: ______

Weight : ______

Remarks:

B.) Blood Pressure:

Remarks:

C.) General Appearance:

D.) Hearing: Hearing aid necessary? Circle one: Yes No

E.) Vision: Right Left Correction necessary? Circle one: Yes No

F.) Circle any abnormalities:

Eyes Sinuses Lungs Back Reflexes

Ears Thyroid Genital Extremities

Nose Chest Rectum Skin

Throat Heart Breast Lymph Nodes

Explanatory Remarks:

MEDICAL HISTORY

A.) Significant medical history:

B.) Past hospitalizations:

C.) Family history (significant medical/psychiatric):

D.) Medicines and reasons for prescribing:

E.) Allergies and/or dietary restrictions:

F.) Any necessary limitations or modifications for individual’s activities:
G.) Diagnosis of alcohol or drug addiction: Please explain.

H.) Immunizations up-to-date? Circle one: Yes No

I.) Do you have any medical concerns about this individual participating in Mercy Volunteer Corps?

PHYSICIAN INFORMATION

Physician’s Name: Date:
Physician’s Signature:
Address:
Phone:

Please use name stamp or attach Rx below.